"Thirty-five years into the “war on drugs”, the United States still has a huge drug abuse problem, with several million problem users of illicit drugs and about 15 million problem users of alcohol. Illicit drug-dealing industries take in about $50 billion per year. Much of the retail drug trade is flagrant, involving either open-air activity or identified, dedicated drug houses. Flagrant dealing creates violence and disorder, wrecking both the neighborhoods where it goes on and the lives of the dealers. Chronic heavy users of expensive illicit drugs steal and deal to finance their habits. Drug injection spreads HIV and hepatitis-C.
On top of all that, we have a highly intrusive and semi-militarized drug enforcement effort that is often only marginally constitutional and sometimes more than marginally indecent.11. For accounts of the “epidemic of isolated incidents” in which innocent people have been killed or injured when their homes were wrongly subjected to SWAT-style searches, see Radley Balko, Overkill: The Rise of Paramilitary Police Raids in America (Cato Institute, 2006). That enforcement effort keeps about 500,000 Americans behind bars at any one time for drug law violations, about 25 percent of the total U.S. prison and jail population. A larger proportion of U.S. residents is doing time for drug law violations than is behind bars for all offenses put together in any country to which we’d like to be compared.
These are depressing facts that cry out for a radical reform to solve the drug problem once and for all. But the first step toward achieving less awful results is accepting that there is no one “solution” to the drug problem, for essentially three reasons. First, the potential for drug abuse is built into the human brain. Left to their own devices, and subject to the sway of fashion and the blandishments of advertising, many people will wind up ruining their lives and the lives of those around them by falling under the spell of one drug or another. Second, any laws—prohibitions, regulations or taxes—stringent enough to substantially reduce the number of addicts will be defied and evaded, and those who use drugs in defiance of the laws will generally wind up poorer, sicker and more likely to be criminally active than they would otherwise have been. Third, drug law enforcement must be intrusive if it is to be effective, and enterprises created for the expressed purpose of breaking the law naturally tend toward violence because they cannot rely on courts to settle disputes or police to protect them from robbery or extortion.
Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.
But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.
The reforms needed to achieve these ambitious goals are radical rather than incremental. But they are not simple, or all of a piece, or in any one of the directions defined by current arguments around American dinner tables, on American editorial pages or in American legislative chambers. The conventional division of drug programs into enforcement, prevention and treatment conceals more than it reveals. So does the standard political line between punitive drug policy “hawks” and service-oriented drug policy “doves.” Neither side is consistently right; some potential improvements in drug policy are hawkish, some are dovish, and some are neither.22. This topic deserves a book rather than an essay, and, as it happens, a fairly good book has recently been published: David Boyum and Peter Reuter, An Analytic Assessment of U.S. Drug Policy (American Enterprise Institute, 2006). To see why, let’s start with the facts.
The Facts Some of the claims below are deliberately controversial, but only in terms of common public discourse. They are not controversial in a scientific sense.
Basics
Most drug use is harmless, and much of it is beneficial—at least if harmless pleasure and relaxation count as benefits. But drug abuse is a real problem all the same because some drug users—typically a fairly small minority among consumers of any given drug—lose control of their behavior when under the influence and do foolish or wicked things. Another overlapping and even smaller group loses control over drug-taking itself. Loss of control in these two forms marks out substance abuse, a diagnosable disease, from non-problem drug use, which may be unconventional but is not pathological.
For most people who fall into its grip, drug abuse is relatively transient. But some drug abusers have a chronic, relapsing form of that disorder: “addiction.” Drug addicts, though a minority of a minority among drug users, constitute the bulk of the drug problem due to the frequency of their misbehavior (both under the influence of drugs and in search of money to acquire drugs), the volume of their drug purchases, and the violence and disorder of the illicit markets they support. Users with substance abuse disorders account for around 80 percent of the volume in the market for an addictive drug.
Not all drugs are equally risky or abusable. But since different drugs are abused in different ways and have different harm profiles, there is no single measure of “harmfulness” or “addictiveness” by which drugs can be ranked. Moreover, the overall damage caused by a drug does not depend on its neurochemistry alone; the composition of the user base and the social context and customs around its use also matter. Alcohol, for example, constitutes a major violence-and-disorder problem in Britain, but not in Italy.
And alcohol is a drug, one that ranks high along most dimensions of risk. Among intoxicants (that is, excluding caffeine and nicotine), alcohol abuse accounts for more than three-quarters of total substance abuse in the United States, and for more death, illness, crime, violence and arrests than all illicit drugs combined. A drug abuse control policy that ignores alcohol is as defective as a naval policy that ignores the Pacific.
Some pairs of drugs are substitutes for one another, so that making one more available will reduce consumption of the other. (Brands of beer compete; beer competes with wine; heroin competes with morphine.) On the other hand, some pairs of drugs are complements, so that making one more available will increase consumption of the other (any depressant is likely complementary with any stimulant, as illustrated both by rum-and-Coke and by the heroin-and-cocaine combination known as a “speedball”). We know much less about these relationships than we should; it isn’t even clear whether making beer more expensive and less available to adolescents would reduce their cannabis use or increase it (and vice versa).
Drug addicts face a strong psychic compulsion to continue to use their favorite drugs, although most of them also have a desire to escape from their addiction. But “compulsive” isn’t the same as “involuntary”: Addicts can and do respond to the conditions and consequences of their behavior. They tend to cut back on drug use and increase their efforts to quit in the face of higher prices, and they respond to rewards for abstaining and punishments for using, as long as the rewards and punishments are swift and predictable.
Laws and law enforcement
Taxes, regulations and prohibitions can reduce drug consumption and abuse, but always at the cost of making the remaining consumption more damaging than it would otherwise be. Any rule restrictive enough to matter needs to be enforced, and enforcement is always costly and damaging to those punished.
All illicit markets are bad; just how bad depends on the size of the market, the flagrancy of the distribution mechanism, and the social mix of users and dealers. At relatively low cost, regulation and prohibition can be effective in preventing the emergence of new problem drug markets, and sometimes in keeping drugs already entrenched in some areas from extending their geographic reach. But once a drug has an established mass market, more enforcement cannot greatly shrink the problem; existing customers will seek out new suppliers, and imprisoned dealers, seized drugs and even dismantled organizations are replaced. Moreover, the effectiveness of enforcement tends to fall over time as the illicit industries learn to adapt. We have 15 times as many drug dealers in prison today as we had in 1980, yet the prices of cocaine and heroin have fallen by more than 80 percent.
Aggressive enforcement against mass drug markets generates mass imprisonment. Imprisonment is necessarily horrible, and most imprisonment in the United States is worse than necessary. Dealers emerging from prison have limited economic opportunities outside the drug trade, forcing down drug-dealing wages and thus drug prices; that seems to have happened with crack.
Some drug dealers commit non-drug crimes of such severity as to justify imprisonment to prevent future victims. However, the average incarcerated dealer commits fewer predatory crimes than the average non-drug prisoner, so filling cells with dealers while prison space is scarce tends on balance to increase the rate of property and violent crime.
Prevention
Drug-use prevention efforts are very cost-effective because they’re very cheap. But they aren’t very effective; even the best programs, combining school-based and community-based efforts, reduce the rate of initiation by no more than a quarter, with no assurance that spending more would produce bigger effects. Most of those initiations are postponed rather than avoided entirely, and there is no direct evidence that deferring drug initiation reduces future addiction. The DARE program, by far the most widespread, is also demonstrably the least effective, with an impact on student drug use indistinguishable from zero after dozens of evaluations.
Treatment
The mantra, “Drug abuse is a chronic, relapsing condition”, is true of only a minority of substance abusers. That group seems typical to casual observers only because its members fill the jails and the treatment programs. Most substance abuse disorders resolve “spontaneously”; that is, without formal treatment. (Of those who have met diagnostic criteria for substance abuse disorder during their lifetimes, fewer than a quarter still do, and only a tiny proportion of those who have recovered have ever been treated professionally.)
Those victims of substance abuse disorders whose attempts to quit or moderate their drug use fail will usually benefit from professional help if they seek it and persist in it. But most people who “need” treatment in the sense that they meet the clinical criteria for substance abuse disorder do not want treatment enough to enter and remain in treatment, even if it is available. The gap between clinically determined treatment need and treatment actually delivered is a function of inadequate demand for treatment as well as inadequate supply.
Those who undergo treatment under legal coercion do as well statistically as though who do so voluntarily. In practice, there is no sharp line between voluntary and involuntary treatment, because those who aren’t coerced by the criminal justice system often enter treatment under other pressures: from their families, for example, or their employers. Conversely, legal coercion to undergo treatment is often more nominal than real: Three-quarters of drug-involved offenders “diverted” from punishment to treatment either fail to appear for treatment at all, or drop out of treatment before completion—and few are punished for it.
Many of those who need treatment—that is, those who cannot get better on their own—cannot readily be “cured”, and that fact is the origin of the “chronic, relapsing condition” theory. But treatment can easily pay for itself by reducing, even temporarily, the level of drug abuse and the resulting harms. In that sense, the slogan “treatment works” is accurate: Those who enter and remain in treatment (voluntarily or otherwise) nearly always improve their condition and their behavior to some extent, and those who enter and remain for a year or more have a good chance of remaining better off and better behaved, even if not entirely abstinent, for some time after treatment ends.
Tobacco
Nicotine in the form of cigarettes is unusually addictive; most smokers are dependent and suffer significant health damage as a result. People who start smoking tend to grossly underestimate their vulnerability to nicotine addiction, or they wouldn’t start. Nine out of ten current smokers want to quit, have tried unsuccessfully to quit, and wish they’d never started.
Pipe and cigar smoking and the use of smokeless tobacco (chewing tobacco and snuff) are much less addictive and much less damaging to health than cigarette smoking. Nicotine use could be made safer by moving users away from cigarettes, by reducing the toxic content of tobacco products (for example, formaldehyde and benzene), or by vaporizing the active agents in tobacco with external heat rather than by burning the leaves, thus delivering nicotine to the lung without the accompanying cloud of hot, toxic gases and particulates.
Hallucinogens
Hallucinogens (“psychedelics”) have a unique risk/benefit profile. Addiction is extremely rare, but users, especially young users, risk injury from accidents and lasting damage from frightening subjective experiences.
The excesses of the 1960s discredited hallucinogens and largely put an end to what seemed like a promising field of research. But former hallucinogen users are far more prone than former users of other kinds of illicit drugs to report that their lives have been lastingly enhanced by their experiences. Recent studies show that these drugs may have clinical potential in reducing the fear of death among terminal patients and in the treatment of some psychiatric problems, including post-traumatic stress disorder. There are also hints that the use of hallucinogens in very low doses might enhance creative work in the arts, the professions, mathematics and the sciences.
Some hallucinogens have been used for religious/spiritual purposes for centuries, if not millennia; the kerkyon, the sacred beverage used in the Eleusinian Mysteries, seems to have contained ergot, a precursor of LSD. A recent experiment at Johns Hopkins University showed that psilocybin, the active agent in “magic mushrooms”, when given under controlled conditions can safely and fairly reliably produce effects indistinguishable from classical mystical experiences, with apparently persistent positive effects on mood and behavior. The Native American Church, which claims a quarter of a million members, has had special legal permission to use mescaline-bearing peyote buttons in its services for more than half a century, and no apparent harm has resulted. The Supreme Court, interpreting the Religious Freedom Restoration Act, has now ruled that other churches using other chemicals may do so lawfully if the religious motive is genuine and the practices reasonably safe.
These facts having now been set out, five principles might reasonably guide our policy choices. First, the overarching goal of policy should be to minimize the damage done to drug users and to others from the risks of the drugs themselves (toxicity, intoxicated behavior and addiction) and from control measures and efforts to evade them.
That implies a second principle: No harm, no foul. Mere use of an abusable drug does not constitute a problem demanding public intervention. “Drug users” are not the enemy, and a achieving a “drug-free society” is not only impossible but unnecessary to achieve the purposes for which the drug laws were enacted.
Third, one size does not fit all: Drugs, users, markets and dealers all differ, and policies need to be as differentiated as the situations they address.
Fourth, all drug control policies, including enforcement, should be subjected to cost-benefit tests: We should act only when we can do more good than harm, not merely to express our righteousness. Since lawbreakers and their families are human beings, their suffering counts, too: Arrests and prison terms are costs, not benefits, of policy. Policymakers should learn from their mistakes and abandon unsuccessful efforts, which means that organizational learning must be built into organizational design. In drug policy as in most other policy arenas, feedback is the breakfast of champions.
Fifth, in discussing programmatic innovations we should focus on programs that can be scaled up sufficiently to put a substantial dent in major problems. With drug abusers numbered in the millions, programs that affect only thousands are barely worth thinking about unless they show growth potential.
A Practical Agenda What would actual policies based on the forgoing facts and principles look like? Here is a “to do” list to get us started:
Don’t fill prisons with ordinary dealers. While prohibition clearly reduces drug abuse (otherwise there wouldn’t be several times as many abusers of alcohol as of all illicit drugs combined), and some level of enforcement is necessary to make prohibition a reality, increasing enforcement efforts against mass-marketed drugs cannot significantly raise the prices of those drugs or make them much harder to acquire. If we had only 200,000 dealers behind bars rather than 500,000, the drug markets would not be noticeably larger, and they might be less violent. Given the fiscal and human costs of incarceration, and the opportunity cost of locking up a drug dealer in a cell that might otherwise hold a burglar or a rapist, the current level of drug-related incarceration is hard to justify. We can reduce that level with arrest-minimizing enforcement strategies and by a discriminating moderation in drug sentencing.
Lock up dealers based on nastiness, not on volume. All drug dealers supply drugs; only some use violence, or operate flagrantly, or employ juveniles as apprentice dealers. The current system of enforcement, which bases targeting and sentencing primarily on drug volume, should be replaced with a system focused on conduct. If we target and severely sentence the nastiest dealers rather than the biggest ones, we can greatly reduce the amount of gunfire, the damage drug dealing does to the neighborhoods around it, and the attractive nuisance the drug trade offers to teenagers.
As a practical matter, too, we cannot create adequate differential disincentives for the most destructive forms of dealing solely by ramping up sanctions for those who engage in them. If we’re already locking up ordinary drug dealers forever, locking up the nastier ones forever and a day won’t create much competitive disadvantage for violence-prone or juvenile-employing organizations. The base level of sanctions needs to be reduced to make differentiated sentencing effective.
Pressure drug-using offenders to stop. The relatively small number of offenders (no more than three million all together) who are frequent, high-dose users of cocaine, heroin and methamphetamine accounts for a large proportion both of theft and of the money spent on illicit drugs. Getting a handle on their behavior is inseparable from getting a handle on street crime and the drug markets.
Yet current policies for dealing with such offenders ignore everything we know both about addiction and deterrence. Ordering drug-using probationers and parolees to enter drug treatment might be effective if we could make the order stick, but it would still be a profligate use of treatment resources. Instead of coercing treatment, we could coerce abstinence directly, insisting that probationers and parolees abstain from the use of illicit drugs. Not every drug-using offender has a diagnosable substance abuse disorder, and insisting (as drug courts do) that every offender have a treatment-needs assessment and a personalized treatment plan sops up scarce capacity, sometimes to the point that poor drug users can’t get treated without getting arrested first.
Whether we demand treatment attendance or abstinence, the hard problem is to make that nominal requirement effective in a population with poor self-control and no great reluctance to break the law. Probation and parole agencies tend to rely excessively on severity at the expense of certainty and immediacy; while most instances of cocaine use by probationers or parolees either go undetected or lead to no sanction beyond a verbal rebuke, some unlucky offenders face revocation of probation or parole and months or even years behind bars.
Instead, we should make the consequences of non-compliance and the rewards of compliance quicker and more reliable. Frequent testing, with automatic and formulaic sanctions for using or missing a test, greatly reduces drug use, and therefore crime, even among chronic user-offenders. Probation or parole revocation—putting the offender behind bars for months, or even years—should be reserved for those who commit serious new crimes or abscond from supervision. The sanction for continuing to use drugs should be no more than a few days in jail. If that threat is made credible, it will generally induce compliance. (Hawaii’s HOPE probation program, based on the “coerced abstinence” model, has reduced the rate of positive drug tests among its clients by 80 percent or more.) Delivering a relatively mild sanction swiftly and consistently is both more effective and less cruel than only occasionally and randomly lowering the boom.
Because rewards are even more potent than punishments, we should also figure out ways of rewarding drug-involved offenders for abstinence. Modest financial incentives greatly reduce cocaine and methamphetamine use in the context of voluntary drug treatment; the trick is to adapt that approach to managing offenders, perhaps by giving a partial remission of fines and fees for each “clean” drug test.
A home meth lab [credit: Associated Press] The benefits of mounting a coerced abstinence program nationally would vastly outstrip its costs, and outstrip the benefits of any other program that could be mounted against drugs and crime using comparable resources. At a guess, a national program costing $5 billion (compared to the total Federal-state-local drug enforcement budget of around $40 billion per year) could reduce the dollar volume in the hard-drug markets by 30 percent, and the savings from incarcerating fewer addicts and fewer dealers would probably more than repay that investment, giving us all the other benefits for free. The administrative and political barriers to such a program are formidable, but the Hawaiian experience suggests that they are not insurmountable. The challenge is to get multiple agencies (probation officers, court clerks, judges, police and jailers) to work together well enough to generate swift and predictable consequences, and to do so at mass scale.
Break up flagrant drug markets using low-arrest crackdowns. Flagrant drug dealing, whether in open-air markets or dedicated drug houses, creates crime, violence and disorder, all of which are deadly to neighborhood life. Even if breaking up such markets doesn’t do much to reduce drug abuse, it does protect the neighborhood. An open drug market is the ultimate “broken window.”
Massive and protracted crackdowns work, but at intolerable expense in police and court resources. But the same effects can be achieved by using explicit and credible threats of arrest and prosecution instead. High Point, North Carolina, broke up a twenty-year-old crack market by identifying and developing cases against all of the active dealers, calling all of them in for a meeting to tell them that dealing must stop at once, and that anyone who persisted could and would be sent to prison based on evidence already in hand. Any one dealer could have been easily replaced, but when all of them stopped at once the market ground to a halt—and anyone who tried to move into the vacuum made himself a sitting duck for law enforcement.
Once the dealers quit, the buyers stopped coming. That forced transactions into more discreet—and less socially destructive—channels such as hand-to-hand transactions in bars or clubs or telephone orders with home delivery.
The hard part wasn’t making the cases and delivering the threats, but identifying the dealers, mobilizing community support for the effort, and lining up social-service providers to offer the involuntarily retired dealers the help they needed to make law-abiding lives for themselves. Winston-Salem, North Carolina, and Newburgh, New York, have had similar success; Kansas City is on deck. That low-arrest crackdowns work is no longer in serious doubt; whether police, prosecutors, and local government leaders will accept the closure of the markets as success, rather than demanding large numbers of arrests and convictions as a mark of “being tough on drugs”, remains an open question.
Deny alcohol to problem drinkers. When someone gets caught drinking and driving, we take away his license: his driving license, that is. The “license” to drink—legal permission to buy and consume alcohol in unlimited quantities—is presumed to be irrevocable. But why? We know that someone who drinks and drives is a bad citizen when drunk, but not that he is a bad driver when sober.
If someone is convicted of drunken driving, or drunken assault, or drunken vandalism, or repeatedly of drunk and disorderly conduct—if, that is, someone demonstrates that he is either a menace or a major public nuisance when drunk—then why not revoke his (or, much more rarely, her) drinking license?33. In a typical American jurisdiction, something like a tenth of one percent of the population consisting of chronic drunk and disorderly arrestees accounts for about 15 percent of all arrests.
Of course, the “personal prohibition” imagined here, like the current age restriction, would have to be enforced by sellers of alcoholic beverages, who would have to verify that each buyer has not been banned from drinking, just as they now have to verify that each buyer is of legal age to drink. Obviously, such a ban could not be perfectly enforced. But reducing the frequency and flagrancy of drinking behavior by problem drunks somewhat is far better than not reducing it at all. A ban on drinking by bad drinkers (unlike the current ban on drinking by those under 21) would have an obvious moral basis. Evading it, for example by buying liquor for someone on the “Do Not Drink” list, would be clearly wrong and worth punishing. Moreover, offenders would not easily be able to drink in bars, restaurants or other public places, which means they would be less likely to drink and then drive or cause public disturbances.
Raise the tax on alcohol, especially beer. The average excise tax (Federal plus state) on a can of beer is about a dime. The average damage done by that can of beer to people other than its drinker is closer to a dollar. Those costs consist mostly of crimes, accidents and the health care costs redistributed through insurance—and the one-dollar figure doesn’t count the costs to the families and friends of drinkers.
Of course, not all drinks are created equal; a dollar per can would be too high a tax on the great majority of drinkers whose drinking does no harm, and too low on the dangerous minority. But in the words of an old Chivas Regal advertisement, “If the extra money matters to you, you’re drinking too much.” (Note that the optimal tax level would fall if we denied alcohol to bad drunks.)
Raising taxes is also among the best ways to reduce heavy drinking by teenagers, for whom price is often a major consideration.
Eliminate the minimum drinking age. There is good evidence that age restrictions reduce underage alcohol abuse and drunk driving. That is true even taking into account the inducement for kids to drink created by making drinking a badge of adulthood and the difficulty of teaching responsible drinking practices to teenagers who are forbidden to drink at all.
But against the benefits we must weigh the costs of making the vast majority of adolescents into lawbreakers. Nearly nine high-school seniors in ten report drinking. Criminalizing statistically normal behavior trivializes lawbreaking by enacting a law that almost everyone breaks, and breaks without apparent harm: Most teenage drinkers, like most adult drinkers, don’t have a drinking problem. The current drinking age has also normalized the acquisition and use of false identification documents, which seems like a bad idea in the age of terror.
The increased teenage drinking that would result from eliminating the age restriction could be offset by a tax increase, leaving us better off all around.
Few of my fellow drug policy analysts agree on this point, so few politicians are likely to vote for such a change. Nonetheless, these three proposed alcohol-policy reforms—higher taxes, personal prohibition for problem drunks, and eliminating the age restriction—would substantially reduce the social costs of the drinking problem.
Prevent drug dealing among kids. Efforts to prevent adolescents from using drugs command widespread support. But next to no attention is paid to the problem of preventing adolescents from dealing drugs. Dealing is a much riskier activity, yet one that still enjoys a certain glamour in some neighborhoods. That glamour could be dulled by introducing some facts about what most dealers actually earn (less than minimum wage) and how likely they are to get shot, jailed or addicted. Even a modest degree of success would be well worth the effort.
Say more than “No.” The current set of messages in most school-based prevention programs—that all drug use is abuse and that cannabis is as dangerous as any other drug—has three big defects. The first is that the messages are false, and lying to schoolchildren is bad. The second is that when the kids figure out that the messages are false—and they do—they won’t believe warnings against harder drugs (or other warnings from the government). The third is that once you’ve told kids that all drug use is abuse, it’s hard to go back and tell them how to keep watch over the circumstances and patterns of their own drug-taking to avoid the transition from non-problem use to abuse. Today, even responsible drinking is a taboo topic. It’s time for the prevention effort to grow up.
Don’t rely on DARE. Drug Abuse Resistance Education, where police come into fifth-grade classrooms, makes kids friendlier toward cops and vice versa, which is all to the good. But it has never been shown to reduce drug use. As a result, the current dominance of DARE means that our drug prevention dollars are preventing less drug use than they might.
Encourage less risky forms of nicotine use. Cigarette smoking, now the overwhelmingly dominant form of nicotine use, is also the form most dangerous to smokers and obnoxious to others. If it were not politically impossible, there would a strong argument for banning cigarette sales to new users, with maintenance supplies for current users.
In the meantime, we should encourage less risky forms of nicotine use. The problem isn’t the nicotine, it’s the dying—400,000 Americans every year. The nicotine phobia of the public health community isn’t hard to understand, but basing policy on that phobia does severe damage to public health.
Let pot-smokers grow their own. Marijuana is an outlier among currently illicit drugs. Its risks are markedly smaller, its consumption is enormously more widespread, and it leads to more arrests than all the others combined—mostly for misdemeanor possession. It is also the one illicit drug that consumers could practically produce themselves. Current cannabis laws criminalize millions of otherwise law-abiding individuals and create a multibillion-dollar illicit market.
Marijuana containers for a New York delivery service [credit: Associated Press] Not that cannabis is harmless. While its “capture rate” to abuse and dependency is substantially smaller than comparable rates for alcohol, cocaine, methamphetamine and heroin, and while the damage from abuse and dependency are usually much less drastic, the rate of capture is still high enough, and the consequences bad enough, to constitute a substantial problem, especially given that the median age of cannabis initiation is now about 15.
Full commercial legalization of cannabis, on the model now applied to alcohol, would vastly increase the cannabis-abuse problem by giving the marketing geniuses who have done such a fine job persuading children to smoke tobacco, drink to excess and supersize themselves with junk food another vice to foster. However, if current laws were changed to make it illegal to sell cannabis or to exchange it for anything of value, but not to grow it, possess it, use it or give it away, the costs of the current control regime could be sharply reduced without greatly increasing the size of the marijuana consumption problem. Such a law could not effectively prevent private sales any more than a ban on gambling can prevent private poker games. Its goal would be to prevent mass marketing.
In the short-to-medium term such a policy would have only a slight impact on use. The biggest effect would be on those who now cease marijuana use as they enter the workforce but might instead keep using the drug. In the long term, there would probably be modest growth in cannabis use due to decreased social stigma and employment risk; how much of that growth in use would be among people who subsequently got into trouble with the drug is harder to guess.
On the other hand, kids who are heavy pot-smokers would no longer be tempted to become dealers. A modest increase in pot-smoking would be a small price to pay for eliminating a huge illicit market, along with several hundred thousand arrests each year and the tens of thousands of prison and jail terms meted out for dealing.
Encourage problem drug users to quit without formal treatment. Some problem drug users need treatment; others do not. Making it widely known that most people with substance abuse problems can recover without professional help would increase the rate of “spontaneous” attempts to quit. Those who try often enough (five failures before success is the average for those trying to quit smoking) are likely to succeed. It won’t work for everyone, but not trying is the only approach certain to fail.
Police lockups, jails and hospital emergency rooms would be good places to screen for abuse, urge abusers to quit on their own if they can, and refer those who can’t to treatment. Those places all see many people with substance abuse disorder at a time when the bad consequences of frequent intoxication are especially salient in their minds. Those opportunities remain largely unexploited.
The other obvious occasion for screening and brief intervention is the annual physical exam; physicians have great credibility in talking about the issue, and have a professional license to ask intrusive questions. But most physicians are not trained in, or compensated for, drug screening and intervention, and the lack of reliable privacy for medical records makes some patients reluctant to answer frankly. Change would require efforts by medical schools, professional societies, managers of health care organizations and the agencies that finance health care.
Expand opiate maintenance. Increasing the capacity of the opiate-maintenance treatment system, which is now grossly over-regulated, could shrink both drug abuse and crime.
Drug treatment works for people who stick with it. Most don’t, but opiate maintenance—treatment with methadone, and the newer and in some ways superior agents buprenorphine and LAAM (l-alpha-acetyl methadol)—has a huge advantage over other addiction treatments: Its clients keep coming back. (There’s no equivalent treatment for stimulant abuse; given the way stimulants work, there probably can’t be.)
We currently have about a million problem opiate users in the United States. Perhaps three-quarters would accept maintenance therapy if it were easily available. Only 100,000 now receive it. One reason is that most judges and probation departments still insist on sending opiate-using offenders to “drug free” therapies. That’s a mistake; the data from California’s Proposition 36 drug-diversion program shows that heroin-using offenders assigned to maintenance programs commit dramatically fewer crimes.
Work on immunotherapies. Imagine stimulating the immune system of a cigarette smoker or a crack user to recognize molecules of nicotine or cocaine as foreign bodies and sop them up in the bloodstream before they reach the brain. It appears that such treatments, consisting of a single injection every month or every few months, are technically feasible for at least some drugs, including nicotine and cocaine. The social benefits of perfecting them and bringing them to market are much larger than the profits a manufacturer could hope to earn.
Immunotherapies should therefore be high priority for public drug-research dollars, especially compared to the expensive and so far largely futile search for drugs to ease the craving that comes from quitting cocaine. (Note that these treatments are technically “vaccines”, but their use is therapeutic, not prophylactic. Mass immunization makes no sense in this context.)
Get drug enforcement out of the way of pain relief. Physicians and their regulators are naturally concerned about the risk of iatrogenic (treatment-induced) drug dependency. Consequently, they have tended to be sparing in their use of opiate and opioid pain relievers, even when the pain involved is extreme and the patient’s short life expectancy, as in the case of terminal cancer patients, makes addiction a largely notional problem. Better professional education has made more recent cohorts of physicians less afraid of over-prescribing painkillers than their older colleagues, but the upsurge of prescription-analgesic abuse (especially of hydrocodone [Vicodin] and oxycodone [Percodan, Oxycontin]) has generated a backlash.
Tight controls and cautious prescribing can reduce medical misuse and recreational use of prescribed drugs and the diversion of pharmaceuticals into illicit markets. A crackdown on Internet pharmacies offering on-line “prescriptions” is fully justified. But the tighter the regulation, the greater the cost and inconvenience imposed on manufacturers, physicians, pharmacists and patients. Cost and inconvenience will not only annoy those groups, it will also increase the amount of untreated pain.
Current policies are scaring physicians away from treating pain aggressively. Many doctors and medical groups now simply refuse to write prescriptions for any substance in Schedule II, the most tightly regulated group of prescription drugs, including the most potent opiate and opioid pain-relievers and the potent amphetamine stimulants. The opiate-and-stimulant combination the textbooks recommend for treating chronic pain is almost never given in practice for fear (a fear well in excess of the actual risk) of disciplinary action and criminal investigation for a physician prescribing “uppers and downers” together. It’s time to loosen up.
Create a regulatory framework for performance-enhancing chemicals. Advances in pharmacology are producing a new wave of molecules capable not merely of curing disease, but of enhancing normal performance across a range of activities: athletic, erotic, cognitive and creative. The borderline between drugs that are necessary to treat real ailments and those that are elective for enhancing performance is already hazy and is bound to become even more indistinct.
Most drug abuse control policy is directed at chemicals people take for fun. (Abuse of anabolic steroids in sports is notoriously widespread, but the number of criminal prosecutions since anabolic steroids were made controlled substances has been tiny, perhaps because steroid abuse doesn’t involve intoxication and is associated with athletic striving rather than the hedonistic “drug culture.”) But we will increasingly confront chemicals people take to perform better.
Insofar as reasonably safe drugs can be developed that lastingly boost memory or other cognitive capacities, it’s not obvious that they ought to be forbidden, or that they should need to be brought in under the guise of treatments for cognitive impairments, as Viagra was brought in to treat erectile dysfunction only to be transformed into an enhancer of normal sexual performance. But let’s not fool ourselves about the nature of competitive pressure. To people playing winner-take-all games in schools, workplaces and sports arenas, any effective performance enhancer that becomes legal will become virtually mandatory for those who don’t want to be outstripped by their competitors. Such chemicals are likely to have long-term side-effects, and we’re virtually certain not to know much about those effects for decades. That makes the regulation of performance-enhancing chemicals a hard problem, and one that can’t safely be left to bioethicists alone.
Figure out what hallucinogens are good for, and don’t let the drug laws interfere with religious freedom. In light of new scientific evidence, it’s time to forget some of the (false) lessons learned from the paisley-and-Day-Glo “psychedelic” episode and bring the potential benefits of responsible hallucinogen use back into the realm of scientific and policy respectability. If hallucinogens have potential for therapy or performance enhancement, why stifle it? If sincere religious seekers want to accept modest risks of injury by taking potentially dangerous chemicals to induce mystical visions, why forbid them?
Stop sacrificing foreign policy and human rights objectives to drug control. Nothing that happens in Colombia or Afghanistan will greatly influence the size of the U.S. drug problem. Drug crops are so plentiful, so cheap and so little restricted by geography that no plausible set of crop-eradication efforts abroad could make any significant difference to the availability of drugs in the United States. And if we can’t make raw drug crops scarce, we shouldn’t weaken the taboo against biowarfare in trying. Even if aerial-spraying campaigns posed no threat to food crops, we’d never convince the world of that.
Given the stakes for us in the current contest between the government in Kabul and the resurgent Taliban for control of Afghanistan, it is absurd for us to insist that President Karzai make large political sacrifices in an inevitably futile attempt to suppress poppy production and opium and heroin exports. Regardless of what level of crackdown on the poppy crop Karzai finds advantageous to winning his civil war—or even if he were to decide to legalize and tax poppy production or even heroin refining—he should have the full backing of the United States. But our government continues to talk (and perhaps act) as if the poppy-production issue matters one way or the other. Given the choice between a Taliban-run Afghanistan and not enforcing the Single Convention on Narcotic Drugs, we should not hesitate a moment in letting the convention go.
As the National Academy of Sciences pointed out a few years ago, one fundamental problem with our current approach to drug abuse is that we don’t know nearly as much as we need to make sound policy. On reason is that the overwhelming bulk of the activity in drug abuse control consists of law enforcement, but almost all of the research money comes from the health side.
The National Institute on Drug Abuse (NIDA), with its billion-dollar annual budget, is part of the National Institutes of Health, making it a biomedical research agency. Drug abuse, however, is only partly a biomedical problem. NIDA has no interest in studying the drug markets or drug enforcement, but that’s where much of the policy action is. More heavy users and more data are to be found by sampling arrestees than by surveying the general population, but we continue to spend tens of millions of dollars a year on a household survey while the very useful Arrestee Drug Abuse Monitoring (ADAM) program was axed by the National Institute of Justice because, at only $7 million a year, it represented a quarter of the tiny part of the NIJ budget not already earmarked by the Congress.
[credit: Peter Bono] Conflict between good and interesting science and the needs of policymaking is typical, not anomalous. Good science is often largely irrelevant to immediate policy; conversely, no one is going to win a Nobel Prize for figuring out how to reduce the violence in street drug markets. Learning more about the brain will surely pay off in the long run, but there is an overwhelming immediate need for more policy-relevant research. If there’s ever the political will to base drug policy on evidence rather than prejudice, the first step must be to get serious about gathering real evidence.
Supervising the national drug policy research agenda, and thinking about how to create less disastrous national drug policies, ought to be part of the job of the Office of National Drug Control Policy (the “drug czar” operation). But instead, that office has been mostly a cheerleader and ideological enforcer, intent on maintaining current ideas and defending the interests of the public and private agencies that provide enforcement, prevention, treatment and drug-testing services. A president who is serious about dealing with the twin problems of drug abuse and drug enforcement, and is prepared to be bold about it, would have to start either by finding smart, knowledgeable, serious and bold people to staff that office—or by getting rid of it entirely. Such a president, alas, is nowhere is sight.
